Every finding on record at Community Hospital of Anaconda

Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 484.22 Emergency Preparedness (EP) Final Rule Requirement for Condition of Participation for Home Health Agencies, effective 11/15/17, a recertification EP survey was performed on 3/17/21. The Emergency Preparedness (EP) survey included a review of 42 CFR §483.73; E-0024 (b)(6), which was completed on 3/17/21. The agency was found to be in compliance with 42 CFR §483.73; E-0024 (b)(6).

Integrated EP Program CFR(s): 484.102(e) §416.54(e), §418.113(e), §441.184(e), §460.84(e), §482.15(f), §483.73(f), §483.475(e), §484.102(e), §485.68(e), §485.625(f), §485.727(e), §485.920(e), §486.360(f), §491.12(e), §494.62(e). (e) [or (f)]Integrated healthcare systems. If a [facility] is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the [facility] may choose to participate in the healthcare system's coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program must- [do all of the following:] (1) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program. (2) Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered. (3) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance [with the program]. (4) Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include the following: (i) A documented community-based risk assessment, utilizing an all-hazards approach. (ii) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach. (5) Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan, and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop an integrated and complete EOP (emergency operations plan), where the separately certified facility's unique circumstances, patient populations and other services are identified. This deficiency has the potential to affect all patients and staff in the agency. Findings include: During an interview on 3/16/21 at 3:14 p.m., staff member B stated the agency was part of the hospital system but was not sure if the hospital's EOP integrated the home health agency's EOP into their overall EOP. She stated she would follow up with staff member O to find out. Staff member B said the agency's plan would be to report to the hospital in the event of an emergency. Review of the agency's EOP showed they had established their EOP to include their overall EP (Emergency Preparedness) plan, communication plan, training's, and drills to participate with the hospital. A review of the hospital's EOP on 3/17/21, showed the hospital's EOP did not include the home health agency as part of their EOP. During an interview on 3/17/21 at 10:00 a.m., staff member O stated the hospital had not developed an integrated EOP to include the home health agency. He stated he was not aware they needed to include the home health agency into the hospital's overall EOP.

A Recertification survey was completed on 3/17/21. The agency was found to be in substantial compliance, and no deficiencies were cited for this survey. A COVID-19 Focused Infection Control (FIC) survey was conducted by the Montana Department of Public Health and Human Services on 3/17/21. The facility was found to be in compliance with 42 CFR §484.70 infection control regulations and has implemented the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. An Emergency Preparedness (EP) survey which included a review of 42 CFR §483.73; E-0024 (b)(6), was completed on 3/17/21. Standard level citations were cited for this survey; the agency was found to be in compliance with 42 CFR §483.73; E-0024 (b)(6). Facility Census: 39